We are currently as a nation discussing health payment reform, but greater reforms are possible.
The system should be technically excellent and as fair as possible to as many as possible.
MEDICAL HOME
I believe a hospital, not an insurance company, should be the medical financial home of an American.
Modern medicine is technology-based and it is expensive and hospital-based.
An American should be able to choose among the two closest hospitals to their home and the one closest to their work. Parents/guardians would choose for children.
The hospital should be required to list on a registry furnished to the Secretary of HHS the doctors it considers acceptable.
No doctor should be refused on the basis of race, gender, religious belief fully compatible with good medical care for patients, sexual orientation, and other factors protecting airline pilots.
The hospital should be able to refuse doctors based on age over 70.
At least 90% of the area doctors in general practice, OB/GYN, and internal medicine and 80% of area nurse practitioners should be listed unless a dispensation on the basis of substantial possibility or showing of incompetence has been granted by the Secretary of HHS. The area selected by the hospital should include at least fifty doctors and at least five in each category.
The hospital need not list every qualified provider. Failure to list a provider should not be cause for legal action.
This hospital should be paid both on a strong capitation basis and a limited fee for service basis.
The sum of capitation and fee for service should be sufficient to run a hospital and pay for doctor care in the eyes of Congress and an independent commission.
The capitation basis should include factors for local labor rates as under Medicare now, customer age, gender, race, weight, and health status factors listed by statute such as diabetes hemoglobin, oxygen saturation levels without artificial oxygen, smoking history, etc.
Those factors that are health dependent should be paid on the basis of good quality medicine after the first year. The hospital shouldn’t get more because its patients are being poorly cared for.
The fee for service amounts should be to adjust for difficult to budget events and for per event costs. Gunshot wounds might be 95% covered, anthrax and Ebola care at 100%, and triple bypass might be only 20% of the current Medicare DRG amount (the remainder would be in capitation). Fee for service adjustments would be set by law and also by HHS administrative grace.
The hospital should be able to charge up to a 10% top-up above the federal capitation amount based solely on its administrative will. This would allow adjustment for the inevitable flawed federal payment formulas and for higher labor costs.
The hospital should also be able to charge up to a 50% top-up above the capitation amount based on the dollar-volume percentage of business it does with full self-pay/insured, travel visa holding medical tourist patients from countries not adjacent to the US. This would allow world-renowned centers of medical excellence in America to charge more.
These capitation top-ups would normally be fully paid by the person selecting the hospital, with a federal subsidy of .5*(percentage of the household poverty level below 200%) being available to the poor. The hospital may freely waive the balance.
Federally-paid capitation top-up amounts may not be used to violate WTO agreements.
If you choose Local Yokel Hospital and then go to World Class Center for non-emergency care, Local Yokel would pay 75% to 100% of the Medicare DRG amount and you and any insurance supplement would have to pay the difference up to the Medicare DRG amount plus any top-up percentage.
In emergency cases, Local Yokel Hospital would pay 90% to 100% of the Medicare DRG amount and you and any insurance supplement would have to pay the difference up to the Medicare DRG amount. World Class may also bill for 2% of the DRG amount to a survivor annually for up to five years.
The exact percentage would be contained in the sign-up sheet of Local Yokel Hospital before you select Local Yokel Hospital.
Hospitals could and would be encouraged to have full patient transparent reciprocity arrangements without violating federal anti-trust law.
Workers Comp would pay for work-related care.
DOCTORS
Doctors and nurse practitioners would generally be paid on a fee for service basis along the present lines by the hospital instead of an insurer or government.
The doctor should be able to charge the patient a premium above the amount based on the dollar-volume percentage of business they do with full self-pay/insured travel visa holding medical tourist patients from countries not adjacent to the US. This would allow world-class doctors in America to charge more. A 10% minimum conforming foreign patient volume would be required to simplify administration.
Doctoring care mainly or fully furnished after 7pm, on a weekend, or a holiday should not be subject to federal income tax if furnished and always billed at Medicare rates.
Doctoring care fully furnished in the patient’s residence or patient’s hotel/motel should not be subject to federal income tax if furnished and always billed at Medicare rates.
MEDICAL CARE
Incident based care would be along the lines of the present system for Medicare recipients.
A person would be charged a reduced co-pay (10% vs. 20%) by going to a nurse practitioner.
Preventative care would be done under the supervision of the hospital you select.
A hospital being paid mainly by capitation would have a strong interest in keeping you well.
The capitation amounts would include fair amounts for preventative care.
The hospital would be expected to ensure you get the preventative care recommended. If you don’t, the hospital would be debited by the government for the missing care.
This preventative care would be very intense. It would be based on the preventative care furnished to sitting presidents and prize race horses. Registered nurses who have received a 4-year degree after 1990 or passed a special test would receive upgraded training to do most the work.
By age 60 people should be getting comprehensive ultrasound scans and blood tests annually.
Older smokers should know where the bronchoscope clinic and outpatient low-dose digital x-ray room are.
Hospitals would get all government tobacco product revenue.
A person prescribed an MRI or CT scan by the ER doctors should be able to get one by paying (or assigning a maximum rate of 8% of the patient’s future federal payments) the evidence-based federal formula amount (one dime to $500) and waiting (five minutes to ~18 hours) for their federal formula priority level or name to be called. A hospital may cut the amount to beef up its scanning revenue.
Amounts on tests should be waived or refunded if the test is used for future treatment.
If you lie and say you have a headache and a spine that hurts, a charge of $499.90 may get levied by the hospital after the scans turn out negative.
DRUGS
Drugs that are generic would be bought at the commercial level.
Drugs that are patented and otherwise exclusive should be bought by the federal government on a national need basis.
The price paid would mainly be based on the per capita amount paid by Canada, Western European and highly advanced Asian nations. The price per dose should not be more effectively 150% that paid in Canada, Britain, France, Germany, or Japan while the drug was under patent in a listed country. Manufacturers should promptly inform drug regulators in each listed country of deficiencies eliminated for the US market and ASAP suggest correction(s) possible for customers in the listed country.
A manufacturing adjustment based on key manufacturing processes (time-release pills, recombinant technology, serum extraction, etc) for increased/decreased quantities should apply unless it would be unfair to the US government.
The price paid would be negotiated with the HHS negotiating team price having presumed validity and being subject to review by a three FDA scientist panel selected by the Commissioner of the FDA and then DC-based federal courts.
A nine-member panel of doctors should allocate breakthrough awards from a $9 billion annual fund. The nine oldest members of the Senate should each be able to name a doctor.
A seven FDA scientist panel selected by the Commissioner of the FDA should also allow research allowances from 90% to 150% based on domestic research expenditures. Its multiplier should not be subject to review.
In the case of drug budgets exceeding the CPI growth*2008 expenditures after 2011, the HHS negotiating team should assess and collect rebates on drugs costing more than $2,000 per use or short series use, or if the medicine is commonly prescribed for over one year, based on an annual cost of $500*an essential molecular weight based factor*an American patient volume factor.
MEDICAL EDUCATION
The current system of doctor education should be allowed to continue.
To ease the mental and financial stress on future medical students, high schools and colleges should develop courses in medical microbiology, medical organic chemistry, clinical anatomy and physiology, and limited drug portfolio prescribing.
These students may then study for a medical specialty at new schools or go to regular medical school.
High school students would be offered a course to recognize the symptoms of disease so they and their loved ones can get care faster or on a schedule such as that for vaccinations.
High school students would be offered a course so they can take care of older persons without unnecessary nursing home placement.
High school students would also be taught about viral and bacteria disease and antibiotic misuse and side effects.
High school students would be taught how to recognize a medical emergency and what medical specialist they might need to select without the aid of a GP.
Diabetics would be offered a community college-based course to manage their disease better.
COST MANAGEMENT COMMISSION
All new drug and device FDA and patent applications should contain the following language:
The price of the product or service submitted for approval may be reduced to an international level by the federal cost management commission or its designated contracting agents if per capita medical costs in the US exceed those of Canada/Germany by more than the following percentages (2010-60%, 2011-55%, 2012-50%, 2013-45%, 2014-40%, 2015-30%, 2016 or thereafter-25%).
LONG-TERM CARE
To avoid neglect of older people and to reduce costs, any person legally authorized to provide care on behalf of a nursing home (i.e. a CNA, LPN, RN, or doctor) may run a four-customer or less one-floor nursing facility. At least one legally authorized caregiver should be present at all times and a second adult should be within five minutes response time away. At least four full-time adults should provide service each day.
A state may lay down reasonable physical requirements above federal requirements.
A monthly $50 inspection fee may be charged by the state where the facility is.
The appropriate nursing and doctor visits should be paid under Medicare Part B.
MALPRACTICE REFORM
Perhaps 3% of the doctors' gross regionally could be placed in a malpractice/bad outcome fund.
To prevent reform windfalls, 80% of a doctor’s current premiums in the first year, 60% in the second year, 40% in the third year, etc. would be charged until the amount is reduced down to 3% of gross.
Panels of four doctors by specialty [obstetrics, internal medicine, etc.] would review cases from the year past and make awards as they see fit.
Lawyers would pay $1,000 per case to be reviewed [$250/review doctor], which would be refunded plus up to $4,000 additional for the lawyer's case prep time and costs if an award was made. No contingency fees would be allowed. Lawyers would generally refer clients to a medical negligence specialist doctor who would prepare a report for the lawyer and doctor claim review panel.
If they award 125% of the local assessments for malpractice alone, awards should be cut 20%.
If they award only 75%, the remaining 25% goes to recommended bad outcomes.
Money not awarded for the current year would go to bump back up cut past awards or into a pot.
Lawyers would only pay 75% as much ($750) and the panel members would only get paid 75% as much if the lawyer states upfront the case is just one of a bad outcome. The lawyer wouldn’t get a prep time fee if the type of case is misstated as malpractice.
This way no money goes to insurers as waste and patients get money.
There is no conflict of interest since the doctors lose 3% of revenue in all years and all situations.
Hospitals might pay 1% of gross revenue annually to be part of review malpractice system.